Thorax

  • Chest Pain
  • Palpitations
  • Shortness of Breath

Chest Pain

  • Differentials 
    • Cardiovascular
      • Acute coronary syndrome
      • Aortic dissection
      • Pericarditis
    • Pulmonary
      • Pulmonary embolism
      • Pneumothorax
      • Pneumonia
    • Gastrointestinal
      • Boerhaave’s Syndrome
      • Pneumomediastinum
      • Gastroesophageal Reflux (GERD)
    • Thoracic Wall
      • Costochondritis
      • Rib contusion/fracture
      • Shingles
    • Psychiatric
      • Anxiety/Panic attack
  • History
    • Ripping/tearing pain?
      • Consider aortic dissection
    • Exertional?
      • Consider ACS, heart failure
    • Pleuritic
      • Consider PE, pericarditis, pneumonia
    • Positional?
      • Consider pericarditis or myocarditis
    • Estrogen use?
      • Consider PE
    • Hx of HTN, HLD, DM, or PVD?
      • Consider ACS
    • Prior cardiac procedures? (stents, bypass, echo, catheterization, etc.)
      • Consider ACS or surgical complications
    • History of anxiety?
      • Consider panic attack
    • Fever/Chills?
      • Consider pneumonia or other infectious causes
  • Physical Exam
    • JVD
      • Suggests right-sided HF
    • New murmurs?
      • Consider valvular dysfunction
    • Abnormal lung sounds? (rales, rhonchi, wheezing)
      • Consider pneumonia, CHF exacerbation, etc.
    • Chest wall tenderness?
      • Consider costochondritis, pericarditis
    • Edema?
      • Consider heart failure
  • Work-Up
    • EKG
      • Look for bradycardia, tachycardia, ST-segment elevation/depression,
    • Labs
      • CBC, BMP
      • Troponin
      • D-Dimer
    • Imaging
      • CXR
      • CT PE (if concern for pulmonary embolism)
      • CT aortogram (if concern for aortic dissection
      • Echocardiogram (if concern for pericardial effusion)
Video Credit: Anna Pickens

*Deep Dive: Chest Pain (SAEM)



Palpitations

  • Differentials 
    • Arrhythmias
      • Sinus tachycardia
      • AVRT/AVnRT
      • Atrial flutter
      • Atrial fibrillation
      • Multifocal Atrial Tachycardia
      • Ventricular Tachycardia
      • PVC’s or PAC’s
    • Valvular Disease
      • Mitral or aortic insufficiency
      • Mitral valve prolapse
    • Psychiatric
      • Panic attack
      • Anxiety
      • Somatization
      • Depression
    • Drug/Medication Use
      • Caffeine
      • Amphetamines
      • Cocaine
      • Aspirin overdose
      • Alcohol/Opiate withdrawal
    • Other
      • ThyrotoxicosisAnemia
      • Addisonian Crisis
      • Carcinoid Syndrome
  • History
    • Recent ingestion of substance?
      • Consider caffeine, amphetamines, or alcohol
    • Recent stressors?
      • Consider anxiety, depression, panic disorder
    • Associated with chest pain/SOB on exertion?
      • Consider ACS, CHF, valvular disorders
  • Physical Exam
    • Murmurs
      • Consider valvular dysfunction
    • JVD
      • Consider heart failure
    • Irregularly irregular heart rate
      • Consider atrial fibrillation/flutter
  • Work-Up
    • EKG
    • Labs
      • CBC, BMP
      • Troponin
      • TSH + Free T4
      • Urine drug screen
      • Pregnancy test
Video Credit: Strong Medicine

*Deep Dive: Palpitations (Merck Manual)



Shortness of Breath

  • Differentials 
    • Airway
      • Airway obstruction
      • Anaphylaxis
      • Abscess or tumor
    • Breathing
      • Asthma
      • Pulmonary embolism
      • COPD exacerbation
      • Pleural effusion
      • Noncardiogenic edema
      • Pneumothorax
      • Pneumonia
    • Cardiac
      • Congestive heart failure
      • Pericardial effusion/Cardiac tamponade
      • Acute Coronary Syndrome
      • Arrhythmia
      • Valvular dysfunction
    • Other
      • Anemia
      • Anxiety/Panic attack
      • Trauma (pulmonary contusion/flail chest)
      • Diabetic Ketoacidosis
      • CO poisoning
  • History
    • Exertional?
      • Suggests ACS, HF, or PE
    • History of previous lung disorders?
      • Consider COPD, Asthma
    • Hx of diabetes?
      • Consider DKA
    • History of cardiac disorders?
      • Consider ACS, HF, valvular problems
    • Recent trauma?
      • Consider pneumothorax, pulmonary contusion
    • Recent travel/immobilization? Estrogen use?
      • Consider pulmonary embolism
    • Fever/chills?
      • Consider infectious causes
  • Physical Exam
    • Apparent distress or tripod positioning
      • Consider need for urgent airway/breathing management
    • Murmurs, rubs, gallops
      • Consider HF, pericarditis
    • JVD
      • Consider right-sided HF
    • Abnormal lung sounds (rales, rhonchi, wheezing)
      • Consider HF, asthma, COPD, pneumonia
  • Work-Up
    • EKG
    • Labs
      • CBC, BMP, troponin, d-dimer, BNP
    • Imaging
      • CT PE (if considering pulmonary embolism)
      • Echo (if suspect effusion, HF)
Video Credit: Strong Medicine

*Deep Dive: Respiratory Distress: An emergency medicine approach (First 10 EM)


Brandon Simpson, PA-S2
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